ACP InternistWeekly

In the News for the Week of 5-3-11

Highlights

Students enjoy internal medicine as a clerkship, not a career

Medical students enjoy their internal medicine clerkships but are less likely than ever to become general internists, citing educational debt, perceived workloads and stress as disincentives, according to a comparison of students in 1990 and 2007. More...

Consensus document advises treating hypertension in those age 80 or older

Major medical organizations last week released an expert consensus document to help clinicians manage older patients with or at risk for hypertension. More...

Test yourself

MKSAP Quiz: 4-cm abdominal aortic aneurysm

A 67-year-old businessman is evaluated during a routine health examination. He has a 30 pack-year history of smoking, but quit 5 years ago. An abdominal ultrasound for screening purposes demonstrates an infrarenal abdominal aortic aneurysm measuring 4 cm in diameter. What is the best management option? More...

ACP recently joined Physicians for Human Rights in a call for Bahrain to cease attacks on hospitals, patients and medical professionals. More...

Regent candidates sought for 2011

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents and is beginning the process of seeking Regents to join the Board in May 2012. More...

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Highlights

Students enjoy internal medicine as a clerkship, not a career

Medical students enjoy their internal medicine clerkships but are less likely than ever to become general internists, citing educational debt, perceived workloads and stress as disincentives, according to a comparison of students in 1990 and 2007.

Researchers compared results from two similar national surveys of senior medical students from 1990 and 2007 that asked about their clerkship experiences and perceptions of internal medicine careers. Results appeared in the April 25 Archives of Internal Medicine.

The two surveys included 1,244 students at 16 schools in 1990 (response rate, 75%) and 1,177 students at 11 schools in 2007 (82%). More students in 2007 reported high satisfaction with their internal medicine clerkships (78% vs. 38%, P<0.001) and more students in 2007 than in 1990 (58% vs. 42%, P<0.001) felt that opportunities for meaningful work in internal medicine were greater than in other specialties.

However, while similar numbers of students planned internal medicine careers in the two survey years (23% vs. 24%), the percentage intending to go into general internal medicine dropped from 9% to 2% (P<0.001).

Students in 2007 were less likely than their 1990 counterparts to say that:

they were attracted to internal medicine by their outpatient rotation (31% vs. 35%, P<0.001), and

their overall internal medicine clerkship made a career in general internal medicine more attractive (19% vs. 24%, P<0.001).

But they were more likely in 2007 to say their clerkship made a career in subspecialty internal medicine more attractive (49% vs. 35%, P<0.001).

Educational loans were a deterrent for more students in 2007 (26% vs. 16%, P<0.001). For the class of 2009, average total educational debt was $132,000 ($158,000 for the 86% of students with debt), and one in four students owed more than $200,000. Meanwhile, the income gap between primary care and subspecialist physicians has grown to nearly threefold, or $3.5 million during a 40-year career, the study authors said.

"Bolder payment and practice reform will be required to reduce the remuneration gap between primary care and subspecialty physicians and to address the adverse work conditions in general internal medicine that students identify in clerkships," the authors wrote. Such policies might include:

expanding scholarships and loans,

addressing work-life balance through new and more satisfying practice models, and

Consensus document advises treating hypertension in those age 80 or older

Major medical organizations last week released an expert consensus document to help clinicians manage older patients with or at risk for hypertension.

While 64% of U.S. men and 78% of U.S. women older than age 80 years have high blood pressure, only one in three men and one in four women have adequate control of their blood pressure, the document noted. Results from the Hypertension in the Very Elderly Trial (HYVET) in 2008 showed clear benefits for using antihypertensive therapy in people age 80 years and older, including a 30% reduction in stroke, 23% reduction in cardiac death, 64% reduction in heart failure and 21% reduction in all-cause mortality. That study became the main impetus for the new consensus document, which was published online April 25.

Some of the consensus recommendations addressed in the consensus document include the following:

Targeting blood pressure less than 140/90 mm Hg in persons age 65 to 79 years and a maximum systolic blood pressure between 140 and 145 mm Hg in persons 80 years and older (if tolerated) was discussed.

Angiotensin-converting enzyme inhibitors, beta-blockers, angiotensin-receptor blockers, diuretics and calcium-channel blockers are all effective in lowering blood pressure and reducing cardiovascular events among the elderly. The choice between drugs should be based on efficacy, tolerability, comorbidities and cost.

Antihypertensive drugs should generally be started at the lowest dose, then increased in gradual increments as tolerated. If the first drug reaches its maximum dose, then a second should be added—a diuretic if it wasn't the first drug. If the antihypertensive response is inadequate after reaching full doses of two classes of drugs, a third drug from another class should be added. When blood pressure is more than 20/10 mm Hg above goal, therapy should be initiated with two antihypertensive drugs. Consider reasons for inadequate response, including polypharmacy, nonadherence and potential drug interactions.

Lifestyle changes may be all that are needed for milder hypertension, and may allow reduction of drug doses. This includes regular physical activity, restriction of salt, weight control, smoking cessation and avoidance of excessive alcohol intake (more than two drinks for men and one drink for women daily).

The high cost of blood pressure-lowering medications contributes to low rates of blood pressure control in the elderly and should be discussed with patients.

The American College of Cardiology (ACC) and the American Heart Association (AHA) released the expert consensus document, which was developed with other medical societies.

Test yourself

MKSAP Quiz: 4-cm abdominal aortic aneurysm

A 67-year-old businessman is evaluated during a routine health examination. He has a 30 pack-year history of smoking, but quit 5 years ago. He consumes two or more alcoholic beverages on most days. He is asymptomatic, but performs no regular physical exercise. He takes no medications.

On physical examination, his blood pressure is 148/92 mm Hg and heart rate is 78/min and regular. His pulses are full, he has no bruits, and results of his lung, heart, abdominal, and rectal examinations are unremarkable.

COPD

Long-acting inhaled beta-agonists were associated with lower mortality than anticholinergics in a new study of chronic obstructive pulmonary disease (COPD).

The retrospective cohort study used health administration data on more than 46,000 Canadian patients with COPD who were newly prescribed either a long-acting inhaled beta-agonist or an anticholinergic between 2003 and 2007. Patients were followed for up to 5.5 years, and results appeared in the May 3 Annals of Internal Medicine.

The overall mortality rate in studied patients was 38.2%. Mortality was 14% increased in patients initially prescribed an anticholinergic compared to those first taking a long-acting beta-agonist (39.9% vs. 36.5%, hazard ratio, 1.14, P<0.001). The anticholinergic group also had higher rates of disease-related hospitalizations and emergency department visits (70.3% vs. 67.8% for both outcomes combined, P<0.001). The rates of mortality and hospital visits were adjusted for a number of factors, including sex, comorbidity and whether patients had undergone spirometry.

This study is thought to be the first to evaluate mortality according to the initial drug class prescribed, the study authors said. Prior research has found them to be equally effective in preventing exacerbations and hospitalizations. Although this study is limited by its observational nature and the associated risk of confounding, it also has certain advantages over randomized controlled trials, the authors said. Randomized trials are often smaller, may exclude sicker and older patients (of which this study had many), and may use patients who are not new to the studied medications. As an observational study, this research was not able to establish the reason for the difference in mortality, but the authors speculated that long-acting anticholinergics may actually increase mortality risk, rather than just reducing it less than the long-acting beta-agonists do.

The results of this study suggest that long-acting beta-agonists may be a better initial therapy for patients with moderate to severe COPD, the authors concluded. They called for randomized controlled trials and research in younger patients to confirm these findings.

Asthma

Omalizumab added to standard therapy may help control severe allergic asthma

Omalizumab may help control severe allergic asthma when added to standard therapy, a new study suggests.

Researchers performed a randomized, double-blind, placebo-controlled trial at 193 sites in the U.S. and four in Canada to determine the efficacy and safety of omalizumab in patients with uncontrolled severe asthma who were receiving high doses of inhaled corticosteroids and long-acting β2-agonists. Patients were randomly assigned to receive omalizumab (dosage was based on body weight and total serum IgE level at screening) or placebo in additional to their existing therapy for 48 weeks. The study's primary end point was the exacerbation rate over the study period. Secondary end points included the change from baseline to week 48 in mean daily puffs of albuterol, mean total asthma symptom score, mean overall score on the standardized Asthma Quality of Life Questionnaire (AQLQ[S]), and frequency and severity of treatment-emergent adverse events. The study, which was industry-funded, appeared in the May 3 Annals of Internal Medicine.

Included patients were 12 to 75 years of age and had at least a one-year history of severe allergic asthma. Asthma was considered to be poorly controlled if patients had persistent symptoms despite current therapy. Four hundred twenty-seven patients were assigned to the omalizumab group, and 423 patients were assigned to the placebo group. Over the 48 weeks of the study, patients who received omalizumab in addition to their existing therapy had statistically significantly fewer asthma exacerbations than those who received placebo (0.66 vs. 0.88 per patient; P=0.006), as well as better AQLQ(S) scores, fewer mean daily albuterol puffs, and lower mean asthma symptom scores. Both groups had similar rates of adverse events (80.4% vs. 79.5%) and serious adverse events (9.3% vs. 10.5%).

The authors acknowledged that almost 21% of patients discontinued therapy early and that their study was not designed to detect rare safety events, among other limitations. However, they concluded that omalizumab appeared to offer additional clinical benefit in patients with severe allergic asthma not controlled by high doses of inhaled corticosteroids and long-acting β2-agonists.

Geriatrics

Levothyroxine dose may be linked to fracture risk in older adults, study suggests

Levothyroxine, especially at higher doses, may be associated with increased fracture risk in older adults, according to a new study.

Researchers performed a nested case-control study using population-based health databases from Ontario, Canada, to examine whether levothyroxine dose affected risk of fracture in older patients. The study included adults at least 70 years of age who had been prescribed levothyroxine between April 1, 2002 and March 31, 2007. Patients were followed for fractures until March 31, 2008. Cases, defined as members of the cohort who had been hospitalized for fracture, were matched with five or fewer cohort controls who hadn't had a fracture. Fracture in relation to current, recent past, or remote use of levothyroxine was the primary outcome. Recent past use was defined as use discontinued within 15 to 180 days of the index date, while remote use was defined as use discontinued more than 180 days before the index date. The study was published online April 28 by BMJ.

Overall, the authors identified 213,511 patients who had used levothyroxine, 22,236 of whom (10.4%) had a fracture over 3.8 years of follow-up. Of those who had fracture, more than three-quarters were women. The mean patient age was 82 years. Current use of levothyroxine was associated with significantly higher fracture risk than remote use (adjusted odds ratio, 1.88 [95% CI, 1.71 to 2.05]). Patients currently taking high (>0.093 mg/d) and medium (0.044 to 0.093 mg/d) cumulative doses of levothyroxine had a statistically significantly increased risk for fracture (adjusted odds ratios, 3.45 [95% CI, 3.27 to 3.65] and 2.62 [95% CI, 2.50 to 2.76], respectively) compared with patients taking low cumulative doses (<0.044 mg/d).

The authors noted that their study did not include laboratory or radiological data and that they did not know the clinical indications for levothyroxine treatment in study participants, among other limitations. However, they concluded that in adults older than 70 years of age, a statistically significant increased risk for fracture may be linked to current use of levothyroxine, and higher doses appear to be associated with greater risk. "Our findings provide evidence that levothyroxine treatment may increase the risk of fragility fractures in older people even at conventional dosages, suggesting that closer monitoring and modification of treatment targets may be warranted in this vulnerable population," they wrote.

The authors of an accompanying editorial agreed, calling for regular monitoring of thyroid-stimulating hormone (TSH) levels in elderly patients. "Further work is needed to see whether current TSH reference ranges (usually 0.4-4.0 mU/L) are appropriate for use in elderly people. If these ranges are not appropriate, this could theoretically exacerbate the risk of overtreatment in elderly people, with increased risk of bone loss and fractures in this high risk group," the editorialists wrote.

From ACP Internist

The next issue is online and coming to your mailbox

The next issue of ACP Internist is online and coming to your mailbox. Top stories include the following.

Food allergies are a tough nut to crack. As public awareness of food allergies increases, identification and management into adulthood can be difficult to sort out, carrying the risk of misdiagnosis, according to specialists who are trying to improve physician education.

Internists don't need to defer treating pain. Pain is one of the most common symptoms seen by primary care physicians, but it can be the most difficult to handle. Chronic pain often requires time-intensive, complex regimens that call for careful management and monitoring, which is not easy to achieve in a busy primary care practice.

Attribution error results from a positive stereotype. In the next installment of Mindful Medicine, a 58-year-old man diagnosed with type 1 diabetes at age 38, a case of latent autoimmune diabetes of adulthood, reports worsening control of his blood sugars despite increasing doses of insulin. An internist must sort through the facts of the case to find out what's responsible.

From the College

College Regent becomes Harvard Department of Medicine's first African-American full professor

Valerie Stone, FACP, a member of ACP's Board of Regents, has been named a full professor at Harvard Medical School and Massachusetts General Hospital (MGH). She is the first African-American full professor in Harvard Medical School's Department of Medicine and the first female African-American full professor at MGH.

Dr. Stone is the director of the primary care internal residency program and associate chief for teaching and training of the general internal medicine division at MGH. She has joint appointments in MGH's and Harvard Medical School's general medicine and infectious diseases divisions.

Dr. Stone received her medical degree from Yale University School of Medicine and did her residency in internal medicine at Case Western Reserve University Hospitals in Cleveland. She completed a health services research fellowship at Harvard and a fellowship in infectious diseases at the Boston University School of Medicine Hospitals. Dr. Stone was elected a College Regent in 2010.

ACP recently joined Physicians for Human Rights (PHR) in a call for Bahrain to cease attacks on hospitals, patients and medical professionals.

In a joint letter sent to the Deputy Supreme Commander of the Bahrain Defense Force, PHR, ACP and several medical groups urge Bahrain to respect its international legal obligations and bring an end to all other violations of medical neutrality. PHR also issued a report titled "Do Not Harm: A Call To End Systematic Attacks on Doctors and Patients," which details the situation in Bahrain. More information on the campaign and the report are online.

Regent candidates sought for 2011

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2012.

The Governance Committee strives to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

Regent candidates must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by August 1, 2011.

Letters of nomination should include the following sections:

Brief description of the nominee's current activities

Special attributes the candidate would bring to the BOR in terms of the desired characteristics outlined above

Previous and current service in College-related activities

Service in organizations other than the College (medical and non-medical)

Identification of two individuals who will write letters of support for the candidate

Letters of support do not need to have specific content or format, but will be most useful if they focus on the candidate's qualifications and how they would contribute to the BOR and College.

Only candidates who submit a letter of nomination and two letters of support by Aug. 1, 2011 will be advanced to the Governance Committee for review. If you have any questions, please contact Florence Moore toll-free at (800) 523-1546, ext 2814, or direct at (215) 351-2814.

MKSAP Answer and Critique

The correct answer is C) Follow-up ultrasound in 6 to 12 months. This item is available to MKSAP 15 subscribers as item 15 in the Cardiovascular Medicine section.

Abdominal aortic aneurysms are an important and treatable cause of mortality, and risk factors such as male sex, smoking history, and aging have been well established. This patient has an asymptomatic small infrarenal aortic aneurysm found on appropriate screening for a man older than 65 years who had previously smoked. Larger aneurysms expand more rapidly, and the rate of growth is important in clinical decision-making regarding intervention. Therefore, the larger the aneurysm is at index detection, the sooner follow-up surveillance should be performed. Two large prospective studies have documented the safety of semi-annual surveillance in patients with aneurysms from 4.0 to 5.4 cm in diameter. Data from the UK Small Aneurysm Trial suggest that a surveillance interval of 24 months may be more appropriate for aneurysms smaller than 4 cm.

An abdominal CT scan with intravenous contrast would clearly demonstrate the aneurysm; however, it would not affect current treatment for this patient and would expose him to unnecessary radiation and the risks of an iodinated contrast agent.

There is no indication for antithrombotic therapy in the treatment of this patient's aneurysm. However, antiplatelet therapy should be considered for cardiovascular primary prevention. Data from several large trials, taken together, suggest benefit of aspirin in middle-aged men for prevention of a first myocardial infarction.

In asymptomatic patients, repair is indicated for aneurysms with a transverse diameter of 5.5 cm or larger, or those demonstrating an expansion rate of more than 0.5 cm/year. In this patient with a 4-cm aneurysm, there is no indication for either surgical or endovascular repair at this time, and the focus should be on surveillance and medical therapy.

This patient has hyperlipidemia and hypertension, and treatment for these conditions is indicated regardless of the aneurysm. Evidence from small randomized trials suggests that statins may inhibit aneurysm expansion. Observational human data suggest that angiotensin-converting enzyme (ACE) polymorphisms may predispose to risk of aneurysm formation, making ACE inhibitors potentially attractive for treatment of hypertension in patients with risk factors for aortic aneurysm. Animal studies with ACE inhibitors and angiotensin-receptor blockers have shown a decrease in the rate of aneurysm expansion, but this has not been demonstrated in humans.

Key Point

For asymptomatic abdominal aortic aneurysms 4.0 to 5.4 cm in diameter, an ultrasound surveillance interval of 6 months has been shown to be safe.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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